The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.

Journal Article > Commentary

Rigid adherence to protocols may detract from safety when unexpected critical events occur that require deviation from the standard process. This commentary explores insights from a physician, both as a clinician and as a new mother, when health care staff failed to effectively consider patient concerns and knowledge in understanding and treating the cause of postlabor pain. The patient identified the cause and requested appropriate treatment, but nurses consulted protocols for pain after labor and only offered pain medications, which might have exacerbated the problem. The author calls for clinician autonomy to recognize when standardization is not appropriate and how to address individual patient needs.

Journal Article > Study

Maternal morbidity has garnered increasing attention as a patient safety issue. This survey of postpartum women elicited reports of adverse events, unanticipated procedures, and sense of betrayal in health care institutions. Patients' reports of adverse events were associated with lack of trust in physicians. Investigators found that patients who reported more engagement in decision-making maintained more trust in physicians than less engaged patients. The authors suggest that shared decision-making may mitigate some of the loss of trust associated with adverse events. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.

Journal Article > Commentary

ACOG Committee on Patient Safety and Quality Improvement and Committee on Professional Liability. Obstet Gynecol. 2016;128:e257-e261.

Disclosure of errors and adverse events is now endorsed by a broad array of organizations. This statement discusses the importance of disclosure and provides resources to help health care organizations develop policies and programs that support a blame-free, learning approach to error that encourages reporting.

Journal Article > Study

Safety culture in labor and delivery wards appears to be suboptimal based on this survey, which found that nearly all physician, nurse, and midwife respondents had witnessed an unsafe patient situation within the past year. However, few respondents had shared their concerns with other staff either formally or informally.

Journal Article > Study

A multifaceted patient safety program resulted in a sustained improvement in safety culture in an academic obstetrics unit. The program had previously been shown to reduce the incidence of preventable adverse events.

This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.

Journal Article > Study

The researchers retrospectively analyzed cases of pregnancy-associated deaths involving anesthesia care and found that system errors, lapses in monitoring, and inadequate supervision by anesthesiologists were factors in the deaths.

Journal Article > Study

This study used a trained observer to monitor obstetric patients for potential adverse events. Based on a predefined set of 72 triggers (eg, admission to intensive care unit, stat cesarean delivery, staff unavailability), the observer captured relevant information about the events, which were later analyzed by a multidisciplinary team. Investigators identified more than 100 triggers, and while very few serious adverse events were described, a number of potential adverse events raised questions about system problems. The authors advocate for use of their methodology to complement existing mechanisms in collecting information on adverse events.

Journal Article > Study

The authors analyzed obstetric trauma data and found that trauma was significantly associated with patient and hospital factors. They conclude that risk of obstetric trauma is not a good indicator of patient safety.

Audiovisual > Audiovisual Presentation

This video, produced by the Partnership for Patient Safety and the Harvard Risk Management Foundation, presents a series of missteps involving a healthy obstetric patient and her unborn infant. Based on actual facts drawn from the experience of the Risk Management Foundation of the Harvard Medical Institutions, this 18-minute film illustrates the value of having a systems awareness in medicine. Deeper explorations of teamwork, hand-offs, communication skills, and managing the authority gradient provide rich examples for viewers. Parts 2 and 3 complete the video series.

Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.

Journal Article > Commentary

Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This commentary explores how data collection gaps, medical errors, ineffective treatments, and care coordination weaknesses contribute to preventable maternal death. The author highlights efforts to improve safety in maternity care such as best practice bundles to ensure teams and clinicians are prepared for certain complications.

Journal Article > Commentary

Maternal harm is a sentinel event that is gaining increased attention in both policy and clinical environments. In this commentary, the author relates her family history of maternal morbidity and mortality and advocates for enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities, accountability, and listening to patients and families who have been impacted by unsafe maternal care.

An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.

A vital component of engaging patients in safety is eliciting their perspective on how they experience both routine care and adverse events. Researchers interviewed women who gave birth in hospitals about what contributed to their sense of safety. Participants emphasized clear communication and empathy as strategies to avoid psychological harm.